Pediatric Cardiac Arrest Algorithm

The Pediatric Cardiac Arrest Algorithm is a clear, step-by-step guide to help healthcare providers treat children whose hearts have stopped or are beating dangerously. It focuses on checking the child’s airway, breathing, and circulation, performing high-quality CPR, using an AED when needed, and giving medicines to improve chances of survival.

This PALS cardiac arrest algorithm guides providers through the critical actions required for resuscitation and achieving a return of spontaneous circulation (ROSC). Key steps include early recognition and activation of the emergency response system, effective CPR, timely defibrillation when appropriate, and careful post-cardiac arrest care.

Note: This Pediatric cardiac arrest algorithm follows the guidelines of 2020-2025 (AHA).

Signs of Pediatric Cardiac Arrest

It is crucial to recognize the signs of pediatric cardiac arrest. Many infants and children show different symptoms, but parents or caregivers may not notice them in time. Key signs include no palpable pulse, no signs of circulation, and unresponsiveness to touch or voice. Skin changes such as paleness, mottling, or a bluish color (cyanosis) often appear quickly as blood circulation stops. Using assessment aids like stethoscopes, providers may hear abnormal heart sounds like PEA or observe heart rhythms on monitors incompatible with adequate blood circulation.

Here are the key signs and symptoms of pediatric cardiac arrest:

Unresponsiveness
Lack of normal breathing or only gasping respirations
No signs of circulation, such as coughing, movement, or normal breathing
Pallor or cyanosis of the skin
Absent pulse
Dilated pupils
Loss of tone, so the child feels limp or floppy
Brassy heart sounds or silence on auscultation
Cardiac rhythm showing asystole, pulseless electrical activity, ventricular fibrillation, or ventricular tachycardia

Treatment of Pediatric Cardiac Arrest

Treating a child in cardiac arrest requires fast and effective action to prevent death. The treatment approach focuses on delivering high-quality chest compressions, providing early defibrillation when needed, ensuring proper airway management and ventilation, and administering the right medications at the right time. These steps work together to restore the child’s heartbeat and improve their chances of survival.

Step 1: Chest compression

Chest compressions are a vital part of treating pediatric cardiac arrest. They help keep blood moving to the brain and other important organs when the heart has stopped. To perform them, place your hands in the correct position on the child’s chest, push hard and fast, and allow the chest to fully rise between compressions. High-quality compressions greatly improve the chances of survival.

Perform chest compression

1. Position your hands: For infants (under 1 year), use two fingers on the center of the chest, just below the nipple line, and for children (1 year to puberty), use the heel of one hand, or both hands if needed, on the center of the chest.
2. Body position: Keep your shoulders directly above your hands or fingers, with elbows straight.
3. Compression depth: Push down about one-third of the chest’s thickness (about 1.5 inches for infants, 2 inches for children).
4. Compression rate: Push at a speed of 100–120 compressions per minute.
5. Allow full recoil: Let the chest rise completely after each push without lifting your hands off the chest.
6. Minimize interruptions: Keep pauses between compressions as short as possible.

Step 2: Pediatric Airway Management

When basic airway techniques such as head-tilt–chin-lift, bag-valve mask (BVM), or mouth-to-mask ventilation are not enough, healthcare providers may use advanced methods to improve oxygen delivery. These include:

1. Endotracheal intubation or supraglottic airway: Inserting a breathing tube into the windpipe (ET tube) or using a supraglottic device to keep the airway open and deliver oxygen directly to the lungs.
2. Waveform capnography or capnometry: Special monitoring tools used to confirm that the breathing tube is in the correct place and to continuously check breathing effectiveness during resuscitation.

Step 3: Defibrillation

Defibrillation is a critical step in treating certain types of pediatric cardiac arrest, specifically ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT). It delivers a controlled electric shock to the heart to stop the abnormal rhythm and allow the heart’s normal rhythm to return. Defibrillation can be performed using automated external defibrillators (AEDs) or manual defibrillation.

Defibrillation Procedure:

1. Attach defibrillator/AED pads to the child’s bare chest (antero-lateral or antero-posterior position as per device instructions).
2. Check rhythm. If VF or pVT is present, prepare to shock.
3. Select energy dose. Provide 2 Joules/kg of first shock followed by 4 Joules/kg of second shock. If needed, provide subsequent shock greater than 4 Joules/kg but not exceeding 10 Joules/kg or the adult maximum dose.
4. Clear everyone from contact with the child before delivering the shock.
5. Deliver shock and immediately resume high-quality CPR for 2 minutes before reassessing rhythm.
6. Continue cycle of CPR, rhythm checks, and shocks as needed, while giving appropriate medications per the algorithm.

Step 4: Medication for Pediatric Cardiac Arrest

Medications can support resuscitation by improving heart function and circulation in children experiencing cardiac arrest. They are given according to the child’s age, weight, and type of cardiac arrest rhythm.

Common medication

1. Epinephrine:

Given for all non-shockable rhythms (asystole or pulseless electrical activity) and sometimes for shockable rhythms after the second defibrillation.
Dose: 0.01 mg/kg IV/IO every 3–5 minutes during resuscitation.

2. Amiodarone:

Used for shockable rhythms (VF/pulseless VT) if defibrillation and CPR are not successful.
Dose: 5 mg/kg IV/IO bolus; may repeat up to 2 times for refractory VF/pVT.

3. Other Medications:

Lidocaine may be used as an alternative to amiodarone for refractory VF/pVT.
Fluids and electrolytes may be given to support circulation if needed.

Reversible Causes of Cardiac Arrest

The American Heart Association highlights the importance of identifying and treating reversible causes during pediatric cardiac arrest. Common causes include hypoxia (low oxygen), hypovolemia (low blood volume), acidosis (acid imbalance), and hypoglycemia (low blood sugar). Less frequent but serious causes, such as tension pneumothorax, cardiac tamponade, toxins, or pulmonary embolism, should also be considered. Recognizing these conditions quickly using the “4 Hs and 4 Ts” framework allows healthcare providers to provide targeted treatment and improve the child’s chance of survival.

The 4 Hs:

Hypoxia: Low oxygen levels in the blood
Hypovolemia: Low blood volume due to bleeding or dehydration
Hypo-/Hyperkalemia & Acidosis: Imbalance of electrolytes or acid-base levels
Hypoglycemia: Low blood sugar

The 4 Ts:

Tension pneumothorax: Air trapped in the chest, causing lung collapse
Tamponade (cardiac): Fluid buildup around the heart, preventing proper pumping
Toxins: Poisoning or drug overdose
Thrombosis: Blood clots in the lungs (pulmonary embolism) or heart

Final Thought on the Pediatric Cardiac Arrest Algorithm

The AHA Pediatric Cardiac Arrest Algorithm is a clear, step-by-step guide for recognizing and treating life-threatening emergencies in children and infants. It serves as a vital resource for healthcare providers, helping them deliver timely, evidence-based care during resuscitation. By following this algorithm, providers can ensure they perform essential actions, such as high-quality CPR, early defibrillation, effective airway management, medication administration, and treatment of reversible causes, in the correct sequence.

The AHA Pediatric Cardiac Arrest Algorithm is an essential tool for healthcare professionals to treat cardiac arrest and prevent severe complications. If you are a healthcare provider, consider CPRVAM’s PALS course to enhance your skills. As an RQI-approved training center, we offer high-quality CPR education to ensure you are prepared to respond confidently in emergencies.

Frequently Asked Questions on PALS Cardiac Arrest Algorithm

1. How Many Breaths Per Minute for Child CPR?

When giving CPR to a child, provide about 20 to 30 breaths per minute if you have an advanced airway in place. If you are doing CPR with chest compressions and rescue breaths, give 2 breaths after every 30 compressions (or after every 15 compressions if two rescuers are present). Each breath should last about 1 second, just enough to make the child’s chest rise.

2. What is the PALS ROSC Algorithm?

The PALS ROSC (Return of Spontaneous Circulation) Algorithm is a step-by-step guide used after a child’s heartbeat and breathing return during resuscitation. It focuses on stabilizing the child, supporting breathing and circulation, controlling blood pressure, checking for underlying causes, and preventing another cardiac arrest. This PALS cardiac arrest algorithm helps improve recovery and long-term outcomes after resuscitation.

3: What is the First step in the Pediatric Cardiac Arrest Algorithm?

The first step is to check the child’s responsiveness. Tap and shout to see if they respond. If there is no response, quickly call for help, activate emergency medical services, and get an AED. This initial check determines whether cardiac arrest treatment is needed and sets the course for the next steps—either starting life-saving interventions or providing care for other serious conditions if the child is not in arrest.

4: What If a Child Has No Pulse After 2 Minutes?

If a child has no pulse after 2 minutes, activate the emergency response system (if not already initiated), then immediately commence CPR. Continue CPR until prompted by an AED for a rhythm check, ensuring continuous lifesaving measures.